The NHS

Baroness Manzoor Excerpts

Thursday 5th July 2018 Lords Chamber

[Lord Darzi of Denham (Lab)]

My Lords, in opening this debate, I declare my interest. I am a practising surgeon in the NHS at St Mary’s Hospital, Paddington, and the Royal Marsden and am the chair of surgery at Imperial College. I proudly sit as a non-executive director of NHS Improvement. Over the past 10 months, I have led an independent review of the health and care system with the Institute for Public Policy Research.

As a surgeon and a former Health Minister, it is a great honour to speak in this place to mark the 70th anniversary of the National Health Service. The NHS is this country’s most treasured institution. It touches our lives at times of the most basic human need when care and compassion matter most. This is a time for reflection to celebrate the institution and give thanks to NHS staff for their service to our nation, and to look to the future.

The NHS is the expression of the moral principle that no one should be denied healthcare because of their means—the idea that the provision of healthcare should be based on need and not the ability to pay. Most people alive today cannot recall the time before the health service was created. With each passing year, the number of people who can recall the pre-NHS era recedes, but if we are to secure its future we must never forget what preceded it.

A friend recently told me the story of his family. His parent worked in the textile mills in Lancashire that have long since disappeared. In the simple kitchen there were two sugar bowls. One was for the sugar and the other for the doctor. It was where they would save a penny or two whenever they could so that, if any member of the family got sick, they could pay for a visit to a doctor. Fear of falling sick was a normal part of daily life in Britain. Illness was the surest path to poverty and destitution, not just for the individuals but for whole families. The founding of the NHS took that fear away for millions and it is a fear that those of us born since have never known and can only imagine.

The NHS was the greatest achievement of the post-war Labour Government. We owe an eternal debt of gratitude to Nye Bevan for his vision, passion and determination to establish the health service. He memorably described the NHS as taking the place of fear. It remains one of the most extraordinary achievements of any society anywhere in the world. It is on occasions such as the 70th anniversary that we must make and remake the case for comprehensive, universal healthcare, free at the point of need for all.

Never let anyone tell you that we cannot afford the NHS. The moral principle of universal access to healthcare is shared by all people everywhere. Those countries that have made it a reality have done so in different ways, but by far the most efficient, dignified and lowest cost is to create a universal service free at the point of need funded by taxation. Private insurance and social insurance systems are much more costly. Those who argue that we cannot afford the NHS are seriously wrong. It is a fundamental error of logic to say that something is unaffordable so we should make the move to something more expensive.

The NHS is funded by us all. It serves each of us and it reflects the best of us. The health service employs 1.5 million people across the four nations of the United Kingdom—that is 5% of all working people in our country. The NHS is its people, not only the doctors and nurses but clinicians of all kinds and the porters, cooks, cleaners and, yes, the vital managers and administrators too. Spending a day working as a porter in the NHS was one of the most illuminating moments of my career. Every member of Team NHS matters. Every one has a contribution to make and each is valuable. I pay tribute to the NHS employees of today who are my colleagues, and to the NHS staff of previous generations. On this day of thanksgiving, we owe them a lasting debt of gratitude.

I have worked in the NHS for longer than I have been a citizen of this country. In a time of great anxiety, I pay a special tribute to the citizens of other countries who have helped to build our NHS throughout its existence and remain the backbone of it today. From the Windrush generation to the European citizens and nationals of every race and creed, from every corner of the world today, they have made an immeasurable contribution. Let that never be forgotten.

NHS staff work at the frontiers of innovation because healthcare exists at the limits of science. This country is a scientific superpower with an extraordinary record of discovery and invention, yet in recent years we have fallen behind on investments in R&D. R&D is the engine of innovation yet R&D spending as a share of GDP has been falling while our competitors have invested more. We need a new commitment to be at the top quartile of advanced countries for R&D investment. The future prosperity of our country depends on it.

Many of the most important medical discoveries took place in this country, often through partnership between the NHS and the universities. No matter the challenges, we are constantly finding new ways to treat disease and soothe pain and suffering. That means that high-quality care is constantly a moving target: to stand still is to fall back. What energises NHS staff is relentlessly improving the quality of care they deliver to their patients. In my review of the NHS with the IPPR we found that, on a wide range of measures, the NHS has maintained and improved the quality of care it provides. Fewer people are harmed and more people are cured than ever before. There is a huge amount to celebrate and to be proud of, yet we should frankly acknowledge the difficulties the health service has faced. The past decade has been the most austere since the health service was founded. Waiting times have risen considerably and the system has been subject to needless destructive reforms. The NHS is not failing, but it is fragile.

A properly funded NHS is the foundation on which a fair, cohesive and inclusive society is built, so the new funding settlement announced by the Prime Minister, the Chancellor and the Secretary of State for Health is very welcome. My friend the noble Lord, Lord Prior, and I, together with the IPPR, recommended a 3.5% annual funding increase: the Government came close, with 3.4%. However, the settlement did not include public health, capital investment or education and training. Each of these is vital and the Government must now deliver on them too.

Securing the NHS is an eternal task. It is no more perfect than life itself. That is why new investment must be joined with reform. Together with the noble Lord, Lord Prior, and the IPPR, I set out a 10-point plan for a 21st-century NHS. At its heart is a new vision, what we call “neighbourhood NHS”, where services are organised around groups of patients with broadly similar needs, rather than groups of professionals with broadly similar skills. We argue that there should be a new option for single integrated care trusts, able to take responsibility for all the health and care needs of a population.

Warm words on mental health must be followed by bold actions. Parity of esteem should mean parity of service. Bringing care closer to people is a crucial principle for a modern NHS, yet for too long the NHS has said it would invest more in care closer to people yet continues to do the inverse of its stated strategy. Each year we say that resources will shift and each year they flow upwards towards hospitals rather than outwards towards communities. That is why we must lock in more spending on primary, community and mental health services each year in the decade ahead.

As we celebrate the past on this anniversary day, we must also look to the future. It is our duty to seize all the technological opportunities that this new era offers. There must be a tilt towards tech to create a digital-first health and care system. That will demand investment in digital infrastructure, improved data sharing and embracing full automation. Many people fear that automation will destroy jobs, but it is much more likely to reshape them by taking away mundane tasks that fill most of our time working in the NHS. This will release more time to care and give more space for clinical reasoning, for research and for innovation.

I have spent decades developing robotic surgery. The robots have yet to replace me, but they have helped me deliver higher-quality care to my patients. For all these improvements to happen, we need a radical simplification of the system. It has become impossibly complicated and is in desperate need of change. I therefore welcome the Prime Minister’s commitment to bring forward legislative change. Tinkering at the edges will not be enough: we need fundamental reform. Above all else, we need to confront the great social challenge of today, which is social care, as we heard earlier.

When the NHS was founded, life expectancy for men was 66 and for women it was just 71. Today, it is 79 and 83 respectively. Today, one-quarter of NHS beds are occupied by patients who are medically fit to go home, if there were good enough support for them. More than £3 billion a year of NHS money is wasted by delayed transfers or transitions of care. If Bevan were designing the health service today, it is unimaginable that he would have excluded social care. We must now extend that simple, noble, brilliant principle of care based on need rather than the ability to pay from the NHS and apply it to social care.

Social care reform has become the third rail of British politics: any politician touching it swiftly expires. Between now and 2030 the number of people over the age of 65 will increase by about one-third and the number of those over 85 will nearly double. At the same time, the working-age population will increase by just about 3%. If we do not act now, a heavy burden will fall on families to take care of their relatives. Since 2010, social care has been slashed. Despite rising demand, state social care has plummeted by 27%. That does not mean that less care has been provided. There has been a dramatic rise in informal care. Critics will argue that the older generation should contribute more of their wealth to pay for social care, particularly the wealth locked up in housing, but tying social care reform to the thorny issue of wealth inequality and taxation is wrong. If we make that hurdle for social care reform, there will be no progress at all. Surely, the level of personal wealth is a better basis for wealth taxation than the need for social care.

Better social care means that families spend less time on functional tasks and more time on relationships. If we want a less lonely and more dignified future for our ageing society, now is the time to act. There could be no better birthday present for the health service. It has been a privilege for me to open this debate, but it has been the greatest honour of my life serving the National Health Service for nearly 30 years. In 30 years from today I hope to see the NHS’s centenary. It is a great comfort to know, for me just as for all of us, that the NHS will be there to provide care and compassion when it matters most.

[Baroness Manzoor (Con)]

My Lords, to assist the House, I say that Back-Bench speeches are limited to four minutes so, when the clock strikes four, time is up.

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[Lord Mawson (CB)]

My Lords, I thank the noble Lord, Lord Darzi, for introducing this important debate. My colleagues and I have been at the cutting edge of the integration agenda for 35 years now. We are today generating a national and international movement and infecting the NHS culture. This year we have welcomed leaders from 23 countries across the world to see our work. Today I am taking our experience to 10 cities and towns in the north of England, through the Well North programme, which I have been asked to lead by the CEO of Public Health England. I declare my interests.

If we are to have an NHS in 70 years’ time, we suggest the following steps, based on hard-won practical experience. First, we must return to the fundamental question raised by the Peckham experiment in 1948, “What is health?”. The NHS closed this project in 1952, saying that its services would now be delivered by the NHS. It was wrong. Some 50% of our patients today do not have a biomedical problem: they have a housing, education or employment problem, or they are lonely. I am finding similar numbers in communities in the north of England. The Bromley by Bow Centre is Peckham mark II, but this time with a business plan.

Secondly, we should stop building health centres. Today we offer a vast array of services to our local community and our 40,000 patients. They stretch from conventional healthcare for local residents to opportunities to set up your own business, from support with tackling credit card debts to help with learning to read and write and help up the career ladder. We should stop building health centres, but that is not to denigrate clinical health. On the contrary, we need to position clinical health within a broad range of services to drive well-being in communities.

The list in this debate question is far too limited. We need to create a locally blended offer, where doctors sit alongside others, including patients and local residents, to provide what people need. It is healthier for doctors. Our health centres are more like a John Lewis store, where the customer is welcomed in and a host of choices are laid before them. The people who run successful department stores know that a diverse product range makes complete sense for the customer and financial sense for the business. You can capture the customer and have an opportunity to offer myriad products and services. It is the same principle in integrated holistic centres, where health is about life and living, not just disease and illness. It is about sweating our community assets. This approach would create benefits and savings across a range of Whitehall departments, not just the Department of Health.

We are working with our partners to build two new town centres in Rotherham and Stocksbridge, just outside Sheffield. The retail sector is challenged at the moment by the internet, but there is a real opportunity to rethink what a town centre is and to put the heart back into it. We will require flexibility and imagination from the NHS and other government departments.

Thirdly, over the years we have developed many innovations that have quietly gone national. The latest is the social prescribing movement which we founded in Bromley. It is now in 20% of GP practices nationally and 80% in Tower Hamlets; there is a network of 2,000 social prescribers across the country. Social prescribing should be the norm in every practice, because it focuses on what matters to patients rather than what is the matter with them. It also ensures maximum engagement with patients in managing their own health. Let us unleash healthy communities.

Finally, there is too much focus on beds and hospitals rather than on early intervention. People believe that the NHS will solve their health problems; often it will not. We are breeding a massive dependency culture through an institution that I would suggest is far from well. Let us be honest. It is not lack of resources that is the problem, but what we have chosen to focus on. I fear more of the same. What happened to the five-year plan? It is time to be more radical. Let us drop the sentimentality about the NHS and return to the fundamental question: what is health in the modern world for our children, in a society that is increasingly atomising? I agree with the noble Lord, Lord Darzi. It is time for fundamental reform, based not on sentiment, theories or ideology but on practical innovation and experience on the ground—and it cannot be led simply by the vested interests of the medical profession.

[Baroness Manzoor]

My Lords, we must keep to time, otherwise noble Lords at the end of the debate will not get their full four minutes.

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[Lord Colwyn (Con)]

My Lords, I welcome the debate of the noble Lord, Lord Darzi. I must also declare my 40 years in the NHS and that I am a fellow of the British Dental Association.

In 1948, the nation’s dental health was in a worse state than that of defeated and occupied Germany; decay and gum disease were rife and more than three-quarters of the adult population had complete dentures. The creation of the NHS meant that, for the very first time, dental care was free at the point of use and the demand was overwhelming. By late 1948, more than 80% of practising dentists had signed up to work in the NHS and, in the first nine months of its existence, NHS dentists provided over 33 million artificial teeth, performed 4.5 million extractions and put in 4.2 million fillings. By 1951, the NHS started running out of money and so charges for dentures were introduced—the first charges of any kind for NHS treatment. This controversial move caused much debate and led to the resignation of Aneurin Bevan. Charges for other types of dental treatment soon followed and, to this day, dentistry remains the only part of the NHS that is not free at the point of use.

NHS dentistry today looks very different from the way it did 70 years ago. Modern technology means that dentistry today is relatively pain free compared with the dentistry of the past. Our nation’s oral health continues to improve and most of us keep at least some of our own teeth past the age of 85. Satisfaction with NHS dentistry is at a record high. Despite an estimated 10 million adults in the UK reporting dental anxiety and 6 million experiencing dental phobia, 85% of patients rate their NHS dental experience as positive.

We cannot, however, afford to be complacent. Although oral health on average is steadily improving for the general population, there are still unacceptable variations in outcomes, depending on where you live. Almost half of five-year-old children living in places such as Pendle, Rochdale or Burnley have tooth decay, but a mere 5% are affected in Waverley or Guildford. Tooth decay remains the leading reason for hospital admissions among young children, despite being almost entirely preventable—a scandal in 21st-century Britain. Increasingly, there are also problems with access to NHS dentistry in many areas. A recent BBC investigation revealed that only 52% of dental practices were able to accept new NHS patients. Almost half of all adults in England—a total of 21 million people—have not seen an NHS dentist for over two years.

The reasons for that can be traced back to two main problems: the lack of funding and a failed dental contract. NHS dentistry has been chronically underfunded in recent years. Nominal spending on dental services per capita fell from £41 in 2013 to £36 in 2017. This drop is even greater if we take into consideration inflation and the rising cost of dental materials. At the same time, patient charges in England have increased at an unprecedented pace—a 5% rise each year for the past three years. Data shows clearly that this fee makes many people delay going to the dentist until the problem has escalated, ultimately requiring more expensive treatment.

The second reason for problems with dental access and rising inequalities in England is the way that dentistry is commissioned. The failed NHS dental contract effectively sets quotas on the number of patients a dentist is able to see on the NHS.

[Baroness Manzoor]

I am so sorry. We are running late and have to go to the next speaker.

[Lord Colwyn]

I have only one more sentence. It has led to such low morale in the workforce that 58% of dentists are looking to leave the NHS in the next five years.